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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Lr5 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City, Lot Size, � PM Owner's Name `` Address � o , /�/ �/� �� f�IPhone Contractor �I` �.�L35 Address � VI99*J License No. �'� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO SPU STALLATION ❑ SYSTEM REPAIR ❑ THER ❑ DISTANCE TO NEAREST: SEPTIC TAN �SEWER LINES"'�''� -DIS SAL FLD. PROP. LINE FOUNDATION (CULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE UCTION SPECIFICATIONS ❑industrial ❑ Open Bottom_: Man _Dia:of Well,Exc Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications V1 1 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ j/ 1 i I i Irrigation .__-Ap Depth I I Eastern Surface Seal Installed by' Repair Work Done ❑.' T of Pump H,P. State Work Done _ Well Destruction Diameter Sealing Material (top 501 f tK Depth Filler Material {f3elaw 50') t i TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION L! DESTRUCTIO (No septic system permitted if public sewer is ) # available within 200 feet.) 4 � Installation will server Residence_____ Commercial_____ Other Number of living units: • Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK © t Type/Mfg Capacity t"�" No. Compartments PKG. TREATMENT PLT. ❑ � ;, , � , Method of Disposal f. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ,Well.-.Foundation Property Line SEEPAGE PITS I I Depth Size.160 . -. Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL POND$ ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- tion laws of California." The applicant must c 1 for atired inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area -711 Pit or Grout Inspection by Data Final Inspection b Date/ Additional Comments:0,-A ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201- FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT NO. + EH 13-24{REV.i/H 51 _ �� 2 V�} k f _ EH 14.26 J / -�